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ObjectiveTo explore how to build and maintain the resilience of frontline healthcare professionals exposed to COVID-19 outbreak working conditions.DesignScoping review supplemented with expert interviews to validate the findings.SettingHospitals.MethodsWe searched PubMed, Embase, PsycINFO, CINAHL, bioRxiv and medRxiv systematically and grey literature for articles focusing on the impact of COVID-19-like working conditions on the physical and/or mental health of healthcare professionals in a hospital setting. Articles using an empirical design about determinants or causes of physical and/or mental health and about interventions, measures and policies to preserve physical and/or mental health were included. Four experts were interviewed to reflect on the results from the scoping review.ResultsIn total, 4471 records were screened leading to an inclusion of 73 articles. Recommendations prior to the outbreak fostering resilience included optimal provision of education and training, resilience training and interventions to create a feeling of being prepared. Recommendations during the outbreak consisted of (1) enhancing resilience by proper provision of information, psychosocial support and treatment (eg, create enabling conditions such as forming a psychosocial support team), monitoring the health status of professionals and using various forms and content of psychosocial support (eg, encouraging peer support, sharing and celebrating successes), (2) tasks and responsibilities, in which attention should be paid to kind of tasks, task mix and responsibilities as well as the intensity and weight of these tasks and (3) work patterns and working conditions. Findings of the review were validated by experts.ConclusionsRecommendations were developed on how to build and maintain resilience of frontline healthcare professionals exposed to COVID-19 outbreak working conditions. These practical and easy to implement recommendations can be used by hospitals and other healthcare organisations to foster and preserve short-term and long-term physical and mental health and employability of their professionals.

Objective To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy. Design Pragmatic, multicentre, cluster randomised controlled trial. Setting 359 general practices in Austria, Germany, Italy, and the United Kingdom. Participants 3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner. Intervention A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual. Main outcome measures The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs. Results 3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 v 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 v 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change −0.42 v 0.06: adjusted mean difference −0.45, 95% confidence interval −0.63 to −0.26; P Conclusions In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes. Trial registration Current Controlled Trials ISRCTN10137559 .

Zusammenfassung Hintergrund Mandeloperationen bei Kindern zählen zu den schmerzhaftesten Eingriffen. Altersgerechte Schmerzskalen sind die Kindliche Unbehagens- und Schmerzskala (KUSS), die Faces Pain Scale–Revised (FPS-R) und der kaum bekannte PPPM-D-Fragebogen. Ziel war Evaluation der Analgesie bei durch Eltern angeforderter Nichtopioid-Medikation (NOM) mit Ibuprofen (IBU) und Paracetamol (PCM) nach intrakapsulärer Tonsillektomie (TO) oder extrakapsulärer Tonsillektomie (TE). Als Rescue-Medikation (RM) wurde nach Prüfung der Schmerzskalen Piritramid appliziert. Endpunkte waren Anteil der Patienten (PAT), der die RM benötigte, Menge applizierter NOM, Übereinstimmung der Indikation in verschiedenen Schmerzskalen, Korrelation von Schmerzen mit Prämedikation und Eingriffsdauer. Material/Methoden Postoperativ erfolgten 3 Messungen täglich mit KUSS bei PAT ≤ 4 Jahre bzw. FPS-R ≥ 5 Jahre. Eltern füllten den PPPM-D aus. Bei einem Wert ≥ 4 bei KUSS bzw. FPS-R oder ≥ 6 im PPPM-D wurde die RM indiziert. Ergebnisse 68 PAT wurden in eine Zwischenauswertung eingeschlossen. Durchschnittliche tägliche NOM in den ersten 3 Tagen: nach TE 14,1–16,3 mg/Kg IBU und 4,2–12,4 mg/Kg PCM bzw. nach TO 10,8–14,7 mg/Kg IBU und 5,2–8,8 mg/Kg PCM. Bei 212 Visiten wurde die RM indiziert, davon 121 Mal nur durch den PPPM-D. Nach Ausschluss eventuell falsch-positiver Indikationen benötigten 67 % der PAT nach TE und 48 % der PAT nach TO mindestens einmal die RM. Die Studie wurde wegen des hohen RM-Bedarfs abgebrochen. Schlussfolgerungen Der Bedarf an NOM wurde unterschätzt. Der PPPM-D kombiniert mit etablierten Skalen kann die postoperative Schmerztherapie verbessern.

Background Proton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool. Methods The arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient. Discussion Our principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care. Trial registration German Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.

Objective We sought to investigate the experiences of general practitioners (GPs) with an electronic decision support tool to reduce inappropriate polypharmacy in older patients (the PRIMA-eDS [Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support] tool) in a multinational sample of GPs and to quantify the findings from a prior qualitative study on the PRIMA-eDS-tool. Materials and Methods Alongside the cluster randomized controlled PRIMA-eDS trial, a survey was conducted in all 5 participating study centers (Bolzano, Italy; Manchester, United Kingdom; Salzburg, Austria; Rostock, Germany; and Witten, Germany) between October 2016 and July 2017. Data were analyzed using descriptive statistics and chi-square tests. Results Ninety-one (n = 160) percent of the 176 questionnaires were returned. Thirty-two percent of the respondents reported that they did not cease drugs because of the medication check. The 68% who had discontinued drugs comprise 57% who had stopped on average 1 drug and 11% who had stopped 2 drugs or more per patient. The PRIMA-eDS tool was found to be useful (69%) and the recommendations were found to help to increase awareness (86%). The greatest barrier to implementing deprescribing recommendations was the perceived necessity of the medication (69%). The majority of respondents (65%) would use the electronic medication check in routine practice if it was part of the electronic health record. Conclusions GPs generally viewed the PRIMA-eDS medication check as useful and as informative. Recommendations were not always followed due to various reasons. Many GPs would use the medication check if integrated into the electronic health record.

Background Within the EU-funded project PRIMA-eDS (Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in older populations by electronic Decision Support) an electronic decision support tool (the “PRIMA-eDS-tool”) was developed for general practitioners (GPs) to reduce inappropriate medication in their older polypharmacy patients. After entering patient data relevant to prescribing in an electronic case report form the physician received a comprehensive medication review (CMR) on his/her screen displaying recommendations regarding missing indications, necessary laboratory tests, evidence-base of current medication, dose adjustments for renal malfunction, potentially harmful drug-drug interactions, contra-indications, and possible adverse drug events. We set out to explore the usage of the PRIMA-eDS tool and the adoption of the recommendations provided by the CMR to optimise the tool and prepare it for its future implementation. Methods In a qualitative study carried out in North Rhine-Westphalia, Germany, 21 GPs using the PRIMA-eDS tool within the PRIMA-eDS study were interviewed. Interviews encompassed the GPs’ attitudes regarding use of the electronic case report form and the CMR, their response to the recommendations, and the implementation of the tool into daily practice routine. The collected data were analysed applying thematic qualitative text analysis. Results GPs found the patient data entry into the electronic case report form to be inconvenient and time-consuming. The CMR was conducted often outside practice hours and without the patient present. GPs found that the PRIMA-eDS CMR provided relevant information for and had several positive effects on the caring process. However, they encountered several barriers when wanting to change medication. Conclusions It is unlikely that the PRIMA-eDS CMR will be used in the future as it is now as patient data entry is too time-consuming. Several barriers towards deprescribing medications were found which are common in deprescribing studies. Given the positive attitude towards the CMR, a new way of entering patient data into the PRIMA-eDS tool to create the CMR needs to be developed. Electronic supplementary material The online version of this article (10.1186/s12875-018-0789-3) contains supplementary material, which is available to authorized users.

Background Polypharmacy is common in older people and associated with potential harms. The aim of this study was to analyse the characteristics of an older multimorbid population with polypharmacy and to identify factors contributing to excessive polypharmacy in these patients. Methods This cross-sectional analysis is based on the PRIMA-eDS trial, a large randomised controlled multicentre study of polypharmacy in primary care. Patients’ baseline data were used for analysis. A number of socioeconomic and medical data as well as SF-12-scores were entered into a generalized linear mixed model to identify variables associated with excessive polypharmacy (taking ≥10 substances daily). Results Three thousand nine hundred four participants were recruited. Risk factors significantly associated with excessive polypharmacy were frailty (OR 1.45; 95% CI 1.22–1.71), > 8 diagnoses (OR 2.64; 95% CI 2.24–3.11), BMI ≥30 (OR 1.18; 95% CI 1.02–1.38), a lower SF-12 physical health composite score (OR 1.47; 95% CI 1.26–1.72), and a lower SF-12 mental health composite score (OR 1.33; 95% CI 1.17–1.59) than the median of the study population (≤36.6 and ≤ 48.7, respectively). Age ≥ 85 years (OR 0.83; 95% CI 0.70–0.99) led to a significantly lower risk for excessive polypharmacy. No association with excessive polypharmacy could be found for female sex, low educational level, and smoking. Regarding the study centres, being recruited in the UK led to a significantly higher risk for excessive polypharmacy compared to being recruited in Germany 1/Rostock (OR 1.71; 95% CI 1.27–2.30). Being recruited in Germany 2/Witten led to a slightly significant lower risk for excessive polypharmacy compared to Germany 1/Rostock (OR 0.74; 95% CI 0.56–0.97). Conclusions Frailty, multimorbidity, obesity, and decreased physical as well as mental health status are risk factors for excessive polypharmacy. Sex, educational level, and smoking apparently do not seem to be related to excessive polypharmacy. Physicians should especially pay attention to their frail, obese patients who have multiple diagnoses and a decreased health-related quality of life, to check carefully whether all the drugs prescribed are evidence-based, safe, and do not interact in an unfavourable way. Trial registration This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559). Electronic supplementary material The online version of this article (10.1186/s12875-018-0795-5) contains supplementary material, which is available to authorized users.

BACKGROUND: Platelet aggregation inhibitors (PAI) are among the most frequently prescribed drugs in older people, though evidence about risks and benefits of their use in older adults is scarce. The objectives of this systematic review are firstly to identify the risks and benefits of their use in the prevention and treatment of vascular events in older adults, and secondly to develop recommendations on discontinuing PAI in this population if risks outweigh benefits. METHODS: Staged systematic review consisting of three searches. Searches 1 and 2 identified systematic reviews and meta-analyses. Search 3 included controlled intervention and observational studies from review-articles not included in searches 1 and 2. All articles were assessed by two independent reviewers regarding the type of study, age of participants, type of intervention, and clinically relevant outcomes. After data extraction and quality appraisal we developed recommendations to stop the prescribing of specific drugs in older adults following the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. RESULTS: Overall, 2385 records were screened leading to an inclusion of 35 articles reporting on 22 systematic reviews and meta-analyses, 11 randomised controlled trials, and two observational studies. Mean ages ranged from 57.0 to 84.6 years. Ten studies included a subgroup analysis by age. Overall, based on the evaluated evidence, three recommendations were formulated. First, the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) in older people cannot be recommended due to an uncertainty in the risk-benefit ratio (weak recommendation; low quality of evidence). Secondly, the combination of ASA and clopidogrel in patients without specific indications should be avoided (strong recommendation; moderate quality of evidence). Lastly, to improve the effectiveness and reduce the risks of stroke prevention therapy in older people with atrial fibrillation (AF) and a CHA2DS2-VASc score of ≥ 2, the use of ASA for the primary prevention of stroke should be discontinued in preference for the use of oral anticoagulants (weak recommendation; low quality of evidence). CONCLUSIONS: The use of ASA for the primary prevention of CVD and the combination therapy of ASA and clopidogrel for the secondary prevention of vascular events in older people may not be justified. The use of oral anticoagulants instead of ASA in older people with atrial fibrillation may be recommended. Further high quality studies with older adults are needed The PRIMA-eDS study was supported by a grant from the European Commission within the 7th Framework Programme (Grant No. 305388–2). The work of YVM was also supported by a grant from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre. The publication charge was funded by the University of Witten/Herdecke

BACKGROUND: Multimorbidity and polypharmacy are common in older people. Assessment tools or lists of criteria aimed at supporting prescription decisions for older people exist, but have often been based on expert opinion with insufficient consideration of the evidence available. The present paper describes the methods we are using to systematically review the existing evidence on the efficacy and safety of the most commonly prescribed drugs for older people in the management of their chronic medical conditions and to develop recommendations to reduce inappropriate prescriptions for incorporation into the Comprehensive Medication Review (CMR) tool developed by the PRIMA-eDS European project. METHODS: We selected the 20 most relevant drugs/drug classes in terms of prescription volumes and risk of hospitalisation for older people and the most relevant indications for the most common chronic conditions among older people and a total of 35 distinct drug-indication pairs were chosen. Based on clinical considerations we collapsed some indications together, reducing the 35 pairs to a final total of 22 separate systematic reviews (SR). A common methodology will be used for each individual SR, based on the methodological manuals of the Cochrane collaboration and the PRISMA statement for reporting systematic reviews. Our search strategy will have a staged approach where we initially search for systematic reviews and meta-analyses, but if relevant reviews are not found, then search for individual studies (controlled intervention and observational studies). Our pilot work and initial scoping of the literature suggested that very few, relevant individual trials or existing systematic reviews have researched or reported exclusively on older people. Therefore, sufficient data might not be available to perform meta-analysis but we will provide a narrative synthesis describing characteristics and findings of included studies. The collected evidence will be used to construct recommendations on when not to use or to discontinue a drug, or when to reduce its dose. Recommendations will be developed in team meetings using the GRADE methodology to reflect the strength of the recommendation and the quality of the evidence. Recommendations will be built into the CMR tool. DISCUSSION: This protocol has been prepared for a series of systematic reviews which will provide research-based evidence to develop recommendations to reduce inappropriate polypharmacy in older people as part of the CMR tool of the PRIMA-eDS project. The PRIMA-eDS study was supported by a grant from the European Commission within the 7th Framework Programme (Grant No. 305388–2). The work of YVM was also supported by a grant from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre. Publication of this article was funded by the UK National Institute for Health Research School for Primary Care Research, University of Manchester.

BACKGROUND: The benefit from a blood pressure lowering therapy with beta blockers may not outweigh its risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of beta blockers in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project. METHODS: Systematic review of the literature using a stage approach with searches for systematic reviews and meta-analyses first, and individual studies only if the previous searches are inconclusive. The target population were older adults (≥65 years old) with hypertension. We included studies reporting on the effectiveness and/or safety of beta blockers on clinically relevant endpoints (e.g. mortality, cardiovascular events, and stroke) in the management of hypertension. The recommendations were developed according to the GRADE methodology. RESULTS: Fifteen studies were included, comprising one meta-analysis, four randomized controlled trials, six secondary analyses of randomized controlled trials and four observational studies. Seven studies involved only older adults and eight studies reported subgroup analyses by age. With regard to a composite endpoint (death, stroke or myocardial infarction) beta blockers were associated with a higher risk of events then were other antihypertensive agents. Further, beta blockers showed no benefit compared to other antihypertensive agents or placebo regarding mortality. They appear to be less effective than other antihypertensive agents in reducing cardiovascular events. Contradictory results were found regarding the effect of beta blockers on stroke. None of the studies explored the effect on quality of life, hospitalisation, functional impairment/status, safety endpoints or renal failure. CONCLUSION: The quality of current evidence to interpret the benefits of beta blockers in hypertension is rather weak. It cannot be recommended to use beta blockers in older adults as first line agent for hypertension. The PRIMA-eDS study was supported by a grant from the European Commission within the 7th Framework Programme (Grant No. 305388–2). The work of YVM was also supported by a grant from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre. The publication charge was funded by the University of Witten/Herdecke.

Background: Oral anticoagulants are used for stroke prevention in patients with atrial fibrillation, the most common cardiac arrhythmia in older adults. The aim of our study was to identify the evidence on the risks and benefits of anticoagulant use among adults aged ≥65 years with atrial fibrillation and to develop recommendations to reduce inappropriate use with a primary focus on new oral anticoagulants. Methods: Systematic review (SR) with search in six databases (up to 12/2016). We included SRs/meta-analyses (MAs) with participants ≥65 years old with atrial fibrillation treated with oral anticoagulation. Two independent reviewers performed study selection, data extraction and quality appraisal. Recommendations were developed based on the evidence identified following a modified GRADE approach. Results: Thirty-eight SRs/MAs were included, drawing on evidence from 74 individual experimental studies. The mean age ranged from 68.2 to 73 years. Treatments investigated included vitamin K antagonists (VKA), new oral anticoagulants (NOACs), platelet aggregation inhibitors (PAI), placebo and no treatment. Comorbidities were reported in 23 SRs, but none reported on frailty status, cognitive status or polypharmacy. Sixteen SRs based on only 3–8 RCTs and thus conveying a significant overlap of studies evaluated the effectiveness of NOACs compared to warfarin. NOACs demonstrated at least equivalent ability to reduce stroke as VKA and a considerably lower risk (OR 0.37 to RR 0.50) of haemorrhagic stroke/intracranial bleeding. Seven SRs were identified comparing VKA to placebo. These revealed a substantial reduction in risk of stroke and mortality for VKA (RR 0.30–0.46)), outweighing an increased risk of bleeding (RR 1.04–3.63) associated with anticoagulation. Eight SRs evaluated the efficacy of VKA compared to PAI: overall, VKA were associated with a lower risk of stroke (OR 0.51–0.68)) and a comparable risk of major bleeding. Conclusions: Anticoagulation treatment using VKA in older people with atrial fibrillation appears beneficial in comparison to PAI and placebo. New oral anticoagulants appear to reduce haemorrhagic strokes and intracranial bleedings more effectively than VKAs and should be considered especially in patients with low TTR (time in therapeutic range)/labile INR (International Normalized Ratio). However, to determine if these results are applicable to all older people, further studies should provide information on frailty, significant impaired renal function, polypharmacy and cognitive status of the participants. The PRIMA-eDS study was supported by a grant from the European Commission within the 7th Framework Programme (Grant No. 305388–2). The work of YVM was also supported by a grant from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre. The publication charge was funded by the University of Witten/Herdecke.

To determine cerebral blood-flow velocity (CBFV) and parameters of dynamic cerebral autoregulation (CA) during and after exhausting resistance exercise. Strength endurance (23 repetitions) and maximal strength training (8 repetitions) in 16 female and 16 male athletes on a leg curler (m. quadriceps training; approx. 2 s contraction) in the upright position. Registration of ECG, blood pressure by Finapres®, CBFV by transcranial Doppler (TCD), and breathing by a Zak® breathing-belt. Additional repetitive ergospirometry (O2-uptake, CO2-elimination, ventilation) and blood gas analyses were performed in a subgroup of seven athletes. From BP and CBFV cerebrovascular resistance (CVR), pulsatility index (PI) as well as LF-power, gain and phase-angle (frequency analysis) were derived. All athletes showed significant (p

Objective:To assess relationships between TV viewing and body composition, energy expenditure, physical activity, fitness and nutrition habits in prepubertal children.Design:Cross-sectional study.Subjects:Sixty prepubertal children (mean body mass index: 20.8 kg m−2, age: 5–11 years, overweight:n=52, normal weight:n=8).Methods:TV consumption, socio-economic status (SES) and nutrition habits were estimated by questionnaires. Fat mass and fat-free mass were assessed by anthropometrics and bioelectrical impedance analysis, and resting energy expenditure by indirect calorimetry. Total energy expenditure was measured by a combination of indirect calorimetry and individually calibrated 24-hour heart rate (HR) monitoring. Activity-related energy expenditure and physical activity level were calculated. Aerobic fitness (VO2submax) was determined by ergometry, muscle strength (musculus quadriceps, musculus ischiocruralis) was measured by computer tensiometry. Children were stratified according to their daily TV consumption: 1 h of TV per day (group II).Results:When compared with children of group I, children of group II had increased body weight, body mass index, skinfolds, fat mass and prevalence of overweight (P2submax but reduced adjusted VO2submax (P−1) and very high (>3 h day−1) TV viewing.Conclusions:There is a positive relationship between TV viewing and fatness. Increased TV viewing does not reflect reduced 24-hour energy expenditure as assessed by 24-hour HR monitoring, submaximal VO2, muscle strength or poor dietary intake. Increased TV consumption is associated with a low SES.

The objective of this cross-sectional study was to assess different attributes of physical activity and fitness and their relationship to nutritional state in endurance- and resistance-trained, compared to untrained men. The subjects were 42 men matched for age, of which 13 were untrained [UT, mean age 30.2 years, mean height 180.7 cm, mean body mass 83.6 kg, mean body mass index (BMI) 25.6 kg.m-2], 14 were endurance-trained athletes (ET, mean age 29.6 years, mean height 178.4 cm, mean body mass 74.0 kg, mean BMI 23.2 kg.m-2) and 15 were resistance-trained athletes (RT, mean age 28.4 years, mean height 183.4 cm, mean body mass 94.1 kg, mean BMI 27.4 kg.m-2). Fat mass (FM), fat free mass (FFM), muscle mass (MM) and total body water (TBW) were assessed using anthropometry and bioelectrical impedance analysis. Resting energy expenditure was measured by indirect calorimetry (IC) and total energy expenditure (TEE) by a combination of IC and individually calibrated 24-h heart-rate monitoring. The activity related energy expenditure (AEE) and the physical activity level were calculated. Movements were assessed using pedometry. Aerobic fitness was determined using ergometry, muscle strength [quadriceps muscle (Famax), ischiocruralis muscle (Fbmax), biceps muscle (Fcmax), triceps muscle (Fdmax)] by computer tensiometry. Different time domain indexes of heart rate variability (HRV) were examined during sleep, rest and the whole day as an index of sympathetic nervous system (SNS) activity. When compared with UT and RT, ET had reduced body masses and FM, but increased percentage TBW (P < 0.05 and P < 0.01, respectively). FFM and MM were increased in RT, when compared with UT and ET (P < 0.01). ET had higher TEE, AEE, pedometry derived activities, oxygen consumption and power during vigorous exercise than RT and UT (P < 0.05 and P < 0.01, respectively). Respiratory exchange ratio at moderate exercise intensities was increased in RT (P < 0.05). In the 12 time domain indexes of HRV 6 and 10 were higher in ET than in RT and UT respectively (P < 0.05 or P < 0.01, respectively) suggesting an increased SNS activity in ET. By contrast, Famax, Fcmax and Fdmax were elevated in RT (P < 0.01). FM was negatively associated with aerobic fitness, but not with muscle strength. We concluded that the physiological and metabolic adaptations to exercise and nutritional state differ between ET and RT subjects. Participation in RT results predominantly in changes in body composition and strength but not in energy expenditure, movements and SNS activity. The opposite was the case for ET. Aerobic fitness, physical activity, movements and activity of SNS were all increased but body mass and FM were decreased. The latter finding may support the idea that, with regard to possible health benefits, ET is more effective than RT.

This was a double-blind randomized study comparing the efficacy of two alpha 1-antagonists, bunazosin retard and prazosin retard, in 185 patients with mild to moderate essential hypertension. Additionally, specific orthostatic tolerance was evaluated by a standardized test (Schellong test). Both 1 to 4 mg prazosin daily and 6 or 12 mg bunazosin daily achieved satisfactory blood pressure reduction (diastolic pressure reduced by at least 10 mm Hg) in 48% and 41% of patients, respectively. The average diastolic blood pressure reduction measured 24 h after drug administration was 9.8 mm Hg in the bunazosin group and 7 mm Hg in the prazosin group. A comparison of blood pressure profiles during specific orthostatic tolerance tests did not show any significant difference between the two groups. However, the symptoms of orthostatic hypotension were significantly less frequent and less severe with bunazosin compared with prazosin. Nineteen patients with essential hypertention were randomized for treatment with either prazosin retard (4 mg) or bunazosin retard (12 mg). The blood flow and the venous capacity were recorded by means of a plethysmograph while the patient was in a supine position and after tilting into the upright position. The peripheral resistance of the calf while the patient was in a supine position during placebo is 38.8 +/- 25.9 U, during bunazosin 28.5 +/- 17 U, and during prazosin 29.7 +/- 27.1 U. The difference between the two alpha-blockers and placebo is statistically significant. There was no effect on venous tone and venous capacity when tilting into the upright position.

This was a double-blind randomised study comparing the efficacy of 2 α1-antagonists, bunazosin retard and prazosin retard, in 185 patients with mild to moderate essential hypertension. Additionally, specific orthostatic tolerance was evaluated by a standardised test (Schellong test). Both prazosin 1 to 4mg daily and bunazosin 6 or 12mg daily achieved satisfactory blood pressure reduction (diastolic pressure reduced by at least 10mm Hg) in 48 and 41% of patients, respectively. The average diastolic blood pressure reduction measured 24 hours after drug administration was 9.8mm Hg in the bunazosin group and 7mm Hg in the prazosin group. A comparison of blood pressure profiles during specific orthostatic tolerance tests did not show any significant difference between the 2 groups. However, the symptoms of orthostatic hypotension were significantly less frequent and severe with bunazosin compared with prazosin.

The purpose of the present study was to assess different aspects of physical activity and fitness in order to develop a basis for sport programmes for overweight and obese children. Eighty-eight prepubertal children (49 boys, 39 girls, 4.8-11.4 years old, 61% obese, 14% overweight and 25% normal weight) were examined. Body composition was assessed by combined use of anthropometrics and bioelectrical impedance analysis. Resting energy expenditure (REE) and total energy expenditure (TEE) were measured by indirect calorimetry (IC) and individually calibrated 24-h heart rate (HR) monitoring, respectively. Activity-related energy expenditure (AEE) and physical activity level (PAL) were calculated from TEE and REE. Fitness [assessed by O2-pulse, respiratory exchange ratio (RER) at submaximal work intensities] was determined by ergometry. The maximal isometric muscle strength of the legs (m. quadriceps, Fa max, m. ischiocruralis, Fb max) was measured by computer tensiometry. Children were grouped according to their nutritional state, AEE, O2-pulse and muscle strength. When compared with normal weight children, obese and overweight children had increased fat mass (FM), fat-free mass (FFM), waist-to-hip ratio and REE, but no group differences were observed for TEE, AEE, and PAL. Obese and overweight children spent more hours per day watching TV. After correction for body weight and FFM, no group differences in REE were observed, but normal weight children had a higher O2-pulse than overweight and obese children. By contrast, RER was increased in the latter group. The fittest group had the lowest body weight, BMI, FM and FFM. Children with a low O2-pulse spent more hours per day watching TV. Grouping children according to their degree of muscle strength, younger children (4-7.5 years) did not show group differences in nutritional state, energy expenditure, physical activity and fitness. However, in the group of 7.6- to 11-year-old children, those with the greatest muscle strength and FFM had reduced BMI, skin folds, FM and FFM. FM correlated inversely with O2-pulse, but was not associated with TEE, AEE, PAL or muscle strength. By contrast TV consumption was positively associated with FM. To summarize, overweight and obese children were less fit and watched more TV than their normal weight counterparts. FM did not correspond to TEE, AEE or PAL. Muscle strength was not associated with FM in young children, but was inversely associated with FM in older children. Our cross-sectional data are consistent with the idea that increased fitness and reduced physical inactivity may prevent children from being overweight.

BACKGROUND: There are limited and controversial data on the influence of gender on metabolic rate in prepubertal children. OBJECTIVE: To assess the effect of gender on resting energy expenditure (REE), activity-related energy expenditure (AEE), total energy expenditure (TEE) and physical activity level (PAL) in free-living prepubertal children. DESIGN: Cross-sectional study. SUBJECTS: 40 prepubertal children (24 boys, 16 girls, 4–11 y old (mean age: 7.0±1.2 y), BMI 13.1–32.0 kg/m2). MEASUREMENTS: Energy expenditure was measured by the combination of indirect calorimetry and individually calibrated 24 h heart rate monitoring. Body composition was assessed by anthropometrics and bioelectrical impedance analysis. Socio-cultural and socio-economic factors, as well as activities of daily living, were estimated by questionnaire for the parents. Boys and girls were matched for fat-free mass (FFM, boys: 25.9±8.5 kg; and girls: 24.4±4.5 kg, n.s.) and fat mass (FM, boys: 11.6±5.9 kg; and girls: 10.8±3.3 kg, n.s.). RESULTS: We found no sex difference in REE, AEE and TEE. PAL was 1.4±0.3 for boys and 1.2±0.4 for girls. REE and TEE were significantly related to FFM (r=0.62, r=0.81, r=0.60). FFM was found to be the most significant determinant of REE (r2=0.70). REE accounted for the largest part of the variance in TEE (r2=0.46). Gender had no significant effect. CONCLUSIONS: There is no effect of gender on energy expenditure in prepubertal children.

When and how did sports medicine and applied physiology start at the University of Ulm? Twenty years ago, on the 6th of June 1974, the Minister of Cultural Affairs of Baden-Wiirttemberg wrote to the University of Vim indicating that the House of Representatives of Baden-Wiirttemberg had decided to establish sports medicine examination centers throughout Baden-Wiirttemberg. This was to be directed and guided by Professor Keul at the University of Freiburg and would include a sports medicine institute at the University of Ulm, with Professor Rieckert at its head. Two months later, however, Professor Rieckert was offered a professorship at the University of Kiel. His move to Kiel led first to Professor Gebert taking over and then Professor Wodik. A redesigning of the program at Ulm subsequently took place, with Professor Stauch being appointed to head Clinical Sports Medicine. In 1970, Professor Brecht was appointed as Director of the Institute of Physiology at the University of Ulm. He, Professor Rieckert who was head of the Sports Medicine Research Program, and Professor Pauschinger the Director of the Institute of Applied Physiology, who worked tirelessly on behalf of the Program formed the nucleus from which the present program evolved. Between 1970 and 1974 Professor Rieckert was the team physician of the Swimming Association of Baden-Wiirttemberg. Every year, swimmers were therefore sent by the Association to the University of Ulm for medical and physiological assessment of their swimming fitness. The general line of sports medical research at that time was exercise physiology.

The arterial blood pressure is integrated into a feedback control system and practically depends on three parameters, i. e. blood volume, heart dynamics, and peripheral resistance. When circulation is disturbed in the orthostatic, the correcting elements heart and vessels have to adapt themselves according to this demand. By standing up, the hydrostatic pressure in the arterial vessels increases rapidly in the lower body regions. The initial increase of the hydrostatic pressure will be stopped by the valves in the venous system. By means of a higher arteriovenous pressure gradient the blood flow into the lower body regions increases more than 100%. The blood flow fills the venous system within 1-2 min successively from downward to upward and opens the valves. The venous pressure in the feet can rise to the full hydrostatic value of 100 mm Hg. This change of pressure causes a volume increase of approximately 200 cm3 regarding both legs of healthy persons. In this way the circulatory blood quantity is reduced. The heart is able to put out shortly an increased cardiac output by loading off the central blood volume (lung and end-systolic volume), in order to compensate orthostatic demand. After a long upright position the cardiac output is falling under the starting value and heart frequency increases. By sympathetic stimulation the peripheral resistance increases as well.

An einem Versuchsgut von 12 kreislaufgesunden jungen Frauen wurden das Verhalten des venosen Gefastonus, der Kreislaufregulation und parallel hierzu einzelne gerinnungsphysiologische Grosen vor und wahrend 2- bis 3monatiger Medikation eines Ovulationshemmers untersucht. Dabei fand sich wahrend der Einnahme eine plethysmographisch erfasbare Zunahme des venosen Gefastonus besonders im Bereich hoherer Druckbelastung, wie sie in der Orthostase zu erwarten ist. Analog hierzu war die Kreislaufregulation unter orthostatischer Belastung verbessert. Die andererseits bei der Untersuchung der Globalgerinnung erkennbare Zunahme der Gerinnungsbereitschaft ist zu gering, um fur sich allein schon das Risiko einer thromboembolischen Erkrankung nennenswert zu vergrosern. Bei der Interpretation der Ergebnisse bleibt zu berucksichtigen, das es sich um kreislaufgesunde Versuchspersonen handelte, die nur uber einen begrenzten Zeitraum hinweg beobachtet werden konnten, und das die Zusammensetzungen der verschiedenen Ovulationshemmer qualitativ und quantitativ betrachtlich voneinander abweichen.

Anhand eines diffus wachsenden, capillaren, teilweise spongiosen Chorangioms der Placenta wird die Frage der placentaren Insuffizienz diskutiert. Mit einem funktionstuchtigen Placentarrest von nur 40 g und einem Geburtsgewicht der Frucht von 2200 g durfte unserer Beobachtung der bisher niedrigste Placentarquotient zugrunde liegen. Daraus resultiert, das Grose und Gewicht erhaltener Placentarstrukturen keinen Masstab fur die Annahme einer placentaren Insuffizienz darstellen konnen. Weitere Uberlegungen galten der Frage der hypoxisch bedingten Kreislaufstorungen am neonatalen Gehirn, da im vorliegenden Fall auf Grund des Alters der Veranderungen geburtstraumatische Schaden auszuschliesen sind.

Eleven amateurs and two internationally ranked windsurfers performed isometric exercise on a windsurfing simulator to the point of exhaustion. The two professional windsurfers maintained their position during exercise two times longer than those of the other group. The following mean values (n = 11) were measured during the exercise: the blood pressure increased from 114 +/- 6.6/70 +/- 11.5 to 177 +/- 8.6/93 +/- 10.3 mmHg, the heart rate from 63 +/- 13 to 103 +/- 16 bts/min, blood flow in the forearm from 6.4 to 7.4 ml/(100 ml tissue x min), and the lactate level in the capillary blood from 0.9 +/- 0.2 to 1.9 +/- 0.4 mmol/l. The post-exercise hyperemia reached values of 28.2 ml/ (100 ml tissue X min). There was neither a significant correlation between the time of exercise and the handgrip force (MVC = maximal voluntary) nor the calculated force of the forearm. Motivation was interpreted as an exercise-prolonging factor. At sea and with high wind (7 Beaufort), the heart rate reached a maximum of 200 bts/min, but the lactate level did not reach more than 3.0 mmol/l.

The short term and the training effects of water immersion and swimming on ventilatory and circulatory parameters of the human organism were described using our own results and data from the literature. It is suggested that swimming has not only the common positive effects on the physical efficiency observed in other types of sport but seems to improve the orthostatic regulation of the circulation. Furthermore, the physical effects of water immersion and the special pattern of muscular activity during swimming favour the adaptation of the heart to the circulatory demands. This advantage of swimming might explain its known beneficial effect in preventive and curative medical treatment.

Sixteen physical education students were tested physiologically to determine the blood flow at the end of three different exercise programs. The blood flow in the calf muscles of the leg was measured by plethysmography for a period of ten minutes: at rest, after a seven minute warm-up period, after a 800 m jog, and after a 5000 m jog. The results of these measurements were recorded for each subject.

Background Multimorbidity is increasing in aging populations with a corresponding increase in polypharmacy as well as inappropriate prescribing. Depending on definitions, 25-50 % of patients aged 75 years or older are exposed to at least five drugs. Evidence is increasing that polypharmacy, even when guidelines advise the prescribing of each drug individually, can potentially cause more harm than benefit to older patients, due to factors such as drug-drug and drug-disease interactions. Several approaches reducing polypharmacy and inappropriate prescribing have been proposed, but evidence showing a benefit of these measures regarding clinically relevant endpoints is scarce. There is an urgent need to implement more effective strategies. We therefore set out to develop an evidence-based electronic decision support (eDS) tool to aid physicians in reducing inappropriate prescribing and test its effectiveness in a large-scale cluster-randomized controlled trial. Methods The “Polypharmacy in chronic diseases–Reduction of Inappropriate Medication and Adverse drug events in older populations” (PRIMA)-eDS tool is a tool comprising an indication check and recommendations for the reduction of polypharmacy and inappropriate prescribing based on systematic reviews and guidelines, the European list of inappropriate medications for older people, the SFINX-database of interactions, the PHARAO-database on adverse effects, and the RENBASE-database on renal dosing. The tool will be evaluated in a cluster-randomized controlled trial involving 325 general practitioners (GPs) and around 3500 patients across five study centres in the United Kingdom, Germany, Austria and Italy. GP practices will be asked to recruit 11 patients aged 75 years or older who are taking at least eight medications and will be cluster-randomized after completion of patient recruitment. Intervention GPs will have access to the PRIMA-eDS tool, while control GPs will treat their patients according to current guidelines (usual care) without access to the PRIMA-eDS tool. After an observation time of 2 years, intervention and control groups will be compared regarding the primary composite endpoint of first non-elective hospitalization or death. Discussion The principal hypothesis is that reduction of polypharmacy and inappropriate prescribing can improve the clinical composite outcome of hospitalization or death. A positive result of the trial will contribute substantially to the improvement of care in multimorbidity. The trial is necessary to investigate not only whether the reduction of polypharmacy improves outcome, but also whether GPs and patients are willing to follow the recommendations of the PRIMA-eDS tool. Trial registration This trial has been registered with Current Controlled Trials Ltd. on 31 July 2014 (ISRCTN10137559). Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1177-8) contains supplementary material, which is available to authorized users.